End-stage kidney disease (ESKD) (kidney failure requiring dialysis or transplantation)
is a costly and disabling condition that often results in premature death (1). During
2019, Medicare fee-for-service expenditures for ESKD were $37.3 billion, accounting
for approximately 7% of Medicare paid claims costs (1). Diabetes and hypertension
remain the leading causes of ESKD, accounting for 47% and 29%, respectively, of patients
who began ESKD treatment in 2019 (1). Compared with White persons, Black, Hispanic,
and American Indian or Alaska Native persons are more likely to develop ESKD (1,
2
) and to have diagnosed diabetes (
3
). After declining for more than a decade, the incidence rate of ESKD with diabetes
reported as the primary cause (ESKD from diabetes) has leveled off since 2010 (1,
4
). Further, after increasing for many years, the prevalence of diagnosed diabetes
has also leveled off (
4
). Although these flattening trends in rates are important from a population perspective,
the trend in the number of ESKD cases is important from a health systems resources
perspective. Using United States Renal Data System (USRDS) 2000–2019 data, CDC examined
trends in the number of incident and prevalent ESKD cases by demographic characteristics
and by primary cause of ESKD. During 2000–2019, the number of incident ESKD cases
increased by 41.8%, and the number of prevalent ESKD cases increased by 118.7%. Higher
percentage changes in both incident and prevalent ESKD cases were among Asian, Hispanic,
and Native Hawaiian or other Pacific Islander persons and among cases with hypertension
or diabetes as the primary cause. Interventions to improve care and better manage
ESKD risk factors among persons with diabetes and hypertension, along with increased
use of therapeutic agents such as angiotensin-converting enzyme (ACE) inhibitors,
angiotensin-receptor blockers (ARB), and sodium-glucose cotransporter 2 (SGLT2) inhibitors
shown to have kidney-protective benefits (
5
,
6
) might slow the increase and eventually reverse the trend in incident ESKD cases.
USRDS collects, analyzes, and distributes ESKD clinical and claims data from the Centers
for Medicare & Medicaid Services (CMS) Medical Evidence Report form (CMS 2728), which
includes sociodemographic characteristics, the date patients were first treated for
ESKD, and the primary cause of ESKD. The Medicare program covers 80% of the cost of
ESKD treatment for beneficiaries in the United States regardless of age (1). Kidney
care providers are required to complete the CMS 2728 form for each new patient with
ESKD, regardless of Medicare eligibility status. Using USRDS 2000–2019 data, CDC examined
the number of incident and prevalent ESKD cases in the United States each year during
2000–2019 by demographic characteristics (i.e., age, sex, and race/ethnicity) and
by primary cause (i.e., diabetes, hypertension, or other cause). This activity was
reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.*
During 2000 and 2019, for both incident and prevalent ESKD cases, 34.9%–42.3% occurred
among persons aged 45–64 years, 53.4%–-58.3% occurred among males, and 44.7%–55.2%
occurred among White persons (Table). During 2000–2019, the number of incident ESKD
cases increased 41.8%, from 92,660 to 131,422 (Table) (Figure 1), and the number of
prevalent cases increased 118.7%, from 358,247 to 783,594 (Table) (Figure 2). Larger
increases among incident cases occurred among Asian (149.5%), Native Hawaiian or other
Pacific Islander (96.5%), and Hispanic (84.0%) persons (Table). Similarly, larger
increases among prevalent cases were also observed among these populations. Smaller
percentage increases in both incident and prevalent cases were observed among persons
aged <45 years and among American Indian or Alaska Native persons. Although diabetes
was the primary cause for a larger percentage of incident and prevalent ESKD cases,
the largest increase in incident and prevalent cases was among patients with hypertension
reported as the primary cause.
TABLE
Number of reported incident and prevalent cases of end-stage kidney disease, by selected
characteristics — United States, 2000 and 2019*
Characteristic
Incident cases
Prevalent cases
2000
2019
Percentagechange
2000
2019
Percentage change
No. (%)†
No. (%)†
No. (%)†
No. (%)†
Total
92,660 (100.0)
131,422 (100.0)
41.8
358,247 (100.0)
783,594 (100.0)
118.7
Age group, yrs
<45
14,194 (15.3)
16,230 (12.3)
14.3
87,769 (24.5)
118,208 (15.1)
34.7
45–64
32,370 (34.9)
48,874 (37.2)
51.0
144,703 (40.4)
331,220 (42.3)
128.9
65–74
23,494 (25.4)
35,744 (27.2)
52.1
71,825 (20.0)
199,005 (25.4)
177.1
≥75
22,602 (24.4)
30,574 (23.3)
35.3
53,950 (15.1)
135,161 (17.2)
150.5
Sex
Men
49,500 (53.4)
76,631 (58.3)
54.8
195,216 (54.5)
456,821 (58.3)
134.0
Women
43,160 (46.6)
54,791 (41.7)
26.9
163,031 (45.5)
326,773 (41.7)
100.4
Race and Ethnicity
White
51,156 (55.2)
67,919 (51.7)
32.8
180,636 (50.4)
349,596 (44.7)
93.5
Black
25,917 (28.0)
33,700 (25.6)
30.0
116,376 (32.5)
234,399 (29.9)
101.4
Hispanic
11,297 (12.2)
20,790 (15.8)
84.0
42,129 (11.8)
140,961 (18.0)
234.6
Asian
2,507 (2.7)
6,256 (4.8)
149.5
11,839 (3.3)
41,393 (5.3)
249.6
American Indian or Alaska Native
1,041 (1.1)
1,299 (1.0)
24.8
4,538 (1.3)
7,949 (1.0)
75.2
Native Hawaiian or other Pacific Islander
742 (0.8)
1,458 (1.1)
96.5
2,729 (0.8)
9,296 (1.2)
240.6
Primary cause
Diabetes
41,458 (44.7)
61,522 (46.8)
48.4
129,699 (36.2)
307,385 (39.2)
137.0
Hypertension
23,384 (25.2)
37,539 (28.6)
60.5
83,553 (23.3)
209,437 (26.7)
150.7
Other cause
27,818 (30.0)
32,361 (24.6)
16.3
144,995 (40.5)
266,772 (34.0)
84.0
* Data from United States Renal Data System, 2021 Annual Data Report, Reference Tables.
https://adr.usrds.org/2021/reference-tables
† Percentages might not sum to 100% because of rounding.
FIGURE 1
Number of reported incident cases of end-stage kidney disease, by primary cause —
United States, 2000–2019*
* Data from United States Renal Data System, 2021 Annual Data Report, Reference Tables.
https://adr.usrds.org/2021/reference-tables
This figure is a histogram showing the number of reported incident cases of end-stage
kidney disease by primary cause in the United States during 2000–2019.
FIGURE 2
Number of reported prevalent cases of end-stage kidney disease, by primary cause —
United States, 2000–2019*
* Data from United States Renal Data System, 2021 Annual Data Report, Reference Tables.
https://adr.usrds.org/2021/reference-tables
This figure is a histogram showing the number of reported prevalent cases of end-stage
kidney disease by primary cause in the United States during 2000–2019.
Discussion
During 2000–2019, in the general U.S. population, the number of reported incident
ESKD cases increased 41.8%, and the number of prevalent cases approximately doubled.
Although persons aged 45–64 years, males, White persons, and persons with ESKD from
diabetes accounted for the larger percentage of cases, Asian, Native Hawaiian or other
Pacific Islander, Hispanic persons, and persons with ESKD from hypertension experienced
the larger increase in cases. Compared with White persons, these racial/ethnic populations
together with American Indian or Alaska Native and Black persons are disproportionately
affected by ESKD (1). The continued increase in the number of ESKD cases will increase
strain on the health care system and lead to higher costs. Effective management of
diabetes and hypertension can help prevent ESKD and decrease the number of incident
cases, thus alleviating the burden on the health care system and reducing costs.
Managing risk factors such as diabetes and high blood pressure and treatment with
ACE inhibitors or ARBs have been shown to help prevent or delay the onset of ESKD
from diabetes (
5
,
7
). In persons with diabetes, ACE inhibitors and ARBs lower blood pressure, reduce
albuminuria, and slow the decline in kidney function (
5
). Other agents such as SGLT2 inhibitors have been shown to reduce the risks for cardiovascular
disease and progression of chronic kidney disease in patients with type 2 diabetes,
in addition to lowering blood glucose (
6
). However, the number of patients with newly treated ESKD from diabetes is likely
to continue to increase with the increasing number of persons with diagnosed diabetes
(
4
).
Compared with White persons, Black, Hispanic, and American Indian or Alaska Native
persons are approximately two to three times as likely to develop ESKD (1,
2
). However, growth in incident and prevalent cases in the American Indian or Alaska
Native population was slower than that in other populations. Population health and
team-based approaches to diabetes care, including kidney disease testing and case
management, implemented by the Indian Health Service, tribal and urban Indian health
facilities, and supported by the Special Diabetes Program for Indians were associated
with an estimated Medicare savings as high as $520.4 million in ESKD cases averted
(
8
). This program might explain the lower percentage change in ESKD cases during 2000–2019.
Expansion of these programs to other populations could reduce morbidity and save costs.
In addition, interventions to promote and increase use of ACE inhibitors, ARBs, and
SGLT2 inhibitors, along with improving care and better managing ESKD risk factors
among persons with diabetes, might slow the increase and eventually reverse the trend
in incident ESKD cases.
ESKD will continue to have a large impact on the U.S. health care system with population
growth, aging, high prevalence of ESKD risk factors such as diabetes, better survival
of the ESKD population, and improved transplant outcomes (1,
3
,
4
). Although the mortality rate in kidney transplant patients is three times lower
compared with patients on dialysis (1), transplant recipients accounted for 3.0% of
the incident and 29.6% of the prevalent ESKD cases in 2019. Further, annual transplant
rates in this population declined somewhat during 2000–2019 (1). Several government
agencies and nongovernmental organizations have implemented initiatives to increase
access to kidney transplants and promote transplantation (
9
). In addition, CMS extended Medicare coverage of immunosuppressive drugs from 36
months to the lifetime of the kidney transplant recipient, preventing the return of
transplant patients to dialysis. This extension of coverage is expected to save Medicare
$400 million over 10 years (
10
). Whereas these factors collectively might result in the continued growth of the
ESKD population, with better management of ESKD, patients can live a healthier life
at a reduced cost to the health care system.
The findings in this report are subject to at least three limitations. First, data
on ESKD treatment were based on reports to CMS; patients whose treatment was not reported
to CMS (e.g., persons who refused treatment or died from ESKD before receiving treatment)
were not included. Second, the primary cause of ESKD was obtained from the CMS Medical
Evidence Report and was based on a physician’s assessment of the patient, which could
be influenced by the physician’s awareness of a diabetes or hypertension diagnosis
and not reflect the true cause of ESKD. Finally, differential classification of race
or ethnicity in the CMS Medical Evidence Form could result in overcount or undercount
of the actual number of ESKD cases in racial- or ethnic-specific groups.
One of the goals of the Advancing American Kidney Health Initiative of the U.S. Department
of Health and Human Services is to reduce the number of Americans developing ESKD
by 25% by 2030 (
9
). Effective management of diabetes and hypertension, including kidney disease testing
and management as part of diabetes care in at-risk populations, can help prevent ESKD.
Monitoring trends and racial or ethnic disparity gaps in ESKD, and tracking other
factors such as kidney disease awareness, pre-ESKD care, and risk factor (e.g., diabetes
or hypertension) control and prevention, will be very important to evaluate the success
of these interventions. Continued efforts to address ESKD risk factors to prevent
or delay ESKD onset could stabilize or reverse the increase in the number of persons
living with ESKD.
Summary
What is already known about this topic?
End-stage kidney disease (ESKD) (kidney failure requiring dialysis or transplantation)
is a disabling condition that often results in premature death. ESKD is costly, accounting
for $37.3 billion of Medicare expenditures during 2019.
What is added by this report?
During 2000–2019, the number of ESKD cases reported in the United States increased
41.8%; the number of prevalent cases approximately doubled. Higher percentage changes
in incident and prevalent ESKD cases were attributable to primary causes related to
diabetes and hypertension.
What are the implications for public health practice?
Effective management of diabetes and hypertension can help prevent ESKD and decrease
the number of incident cases, thus reducing costs and alleviating the impact on the
health care system.